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Bronchiolitis

Clinical Assessment

Mild - Good colour out of oxygen, respiratory rate < 40/min, feeding well.

Moderate - Respiratory rate 40-70/min, mildly cyanosed in air, some difficulty feeding.

Severe - Respiratory rate > 70/min, cyanosed in air, not feeding.

Management

  • Mild - Nurse in an ordinary cot and continue oral feeding.

  • Moderate - Nurse in oxygen. If not dehydrated, wait 2-4 hours for the baby to settle and then try oral feeds in the oxygen cot. If they will not feed orally, insert an IV and give 0.18% saline and 4% dextrose at 80% normal maintenance requirements. If the child is unable to take sufficient volumes of fluids orally, fluids are to be given intravenously. The use of nasogastric feeds increases the risk of aspiration and clinical deterioration.

    Quarter hourly observations of pulse rate, respiratory rate and colour until the baby has settled.

  • Severe - Nurse flat on abdomen in an oxygen cot or head box with an FiO2 of 60-70%. Commence IV fluids as above. Avoid any unnecessary disturbance. Use a monitor to record the pulse rate and ask the nursing staff to record quarter hourly pulse rate, respiratory rate and colour. Consider pulse oximetry and blood gases if the baby does not settle.

  • Transfer to Paediatric ICU if the PaCO2 is > 75 mmHg, if the baby is very distressed or there are any apnoeic episodes.

Investigations

  1. NPA for immunofluorescence and culture.
  2. CXR - In Radiology if mild to moderate respiratory distress; on the ward if severe respiratory distress.

Progress

The baby is taken out of oxygen when it is feeding well. Discharge is usually 24 hours after coming out of oxygen even if there are residual physical signs in the chest.

Follow-up

The majority of infants do not require follow-up. The patients who should be seen after discharge are those with extensive radiological changes, those who were very ill, and those with unusual features (eg failure to thrive).

Remember that many other conditions can present with a bronchiolitis picture such as CF, pneumonia, congenital lung or heart disease, milk inhalation etc.